1. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 18 Eating Disorders

2. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Eating disorders can be viewed on a continuum: the anorexic eats too little, the bulimic eats chaotically, and the obese person eats too much Eating disorders overlap: 50% of clients with anorexia exhibit bulimic behavior; 35% of normal-weight clients with bulimia have a history of anorexia More than 90% of clients with eating disorders are female Eating Disorders

3. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Anorexia Nervosa Refusal or inability to maintain a minimally normal body weight Intense fear of gaining weight or becoming fat Significantly disturbed perception of the shape or size of the body Steadfast inability or refusal to acknowledge the seriousness of the problem or even that one exists

4. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 85% or less of expected body weight Amenorrhea Preoccupation with food and food-related activities Restricting subtype loses weight dieting, fasting, or excessively exercising Binge eating and purging subtype engages in binge eating followed by purging Anorexia Nervosa (cont’d)

5. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Onset and clinical course –Typically begins between 14 and 18 years of age –Ability to control weight gives pleasure to the client –Client may feel empty emotionally and be unable to identify or express emotional feelings –As illness progresses, depression and labile moods are common Anorexia Nervosa (cont’d)

6. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Client is socially isolated, mistrustful of others; may believe that others are trying to make her fat and ugly Long-term studies show: –30% recover –30% partially improve –30% remain chronically ill –10% die of anorexia-related causes Anorexia Nervosa (cont’d)

7. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Bulimia Nervosa Characterized by recurrent episodes of binge eating, then compensatory behaviors to avoid weight gain (purging, use of laxatives, diuretics, enemas, emetics, fasting, excessive exercise) Binge eating is done in secret Client recognizes behavior as pathologic, causing feelings of guilt, shame, remorse, or contempt Usually normal weight

8. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Begins about age 18 or 19 Binge eating begins after an episode of dieting Between binges, eating may be restrictive Food is hidden in the car, desk at work, and secret locations around the house Behavior may continue for years before it is discovered Onset and Clinical Course

9. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Long-term studies show: –50% recover –20% continue to be bulimic –30% have episodic bouts of bulimia One third of fully recovered clients have a relapse Death rate for bulimia is 3% or less Onset and Clinical Course (cont’d)

10. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Related Disorders Rumination disorder, pica, and feeding disorder are diagnosed in infancy and childhood Binge eating disorder is binge eating without regular use of inappropriate compensatory behaviors Night eating syndrome (NES) is morning anorexia, evening hyperphagia (consuming 50% of daily calories after the last evening meal), and nighttime awakenings (at least once a night) to consume snacks

11. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Biologic factors –Genetic vulnerability –Disruptions in the nuclei of the hypothalamus relating to hunger and satiety (satisfaction of appetite) –Neurochemical changes are seen, but it is not known if these changes cause the disorders or are a result of eating disorders Etiology

12. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology (cont’d) Developmental factors –Struggle to develop autonomy and identity –Overprotective or enmeshed families –Body image disturbance and body image dissatisfaction –Separation–individuation difficulties

13. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology (cont’d) Family influences –Families without emotional support –Physical neglect, sexual abuse, or parental maltreatment –Little care, affection, and empathy –Excessive paternal control, unfriendliness, or overprotectiveness

14. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Sociocultural factors –Media –Pressure from peers, parents, and coaches Etiology (cont’d)

15. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Cultural Considerations Eating disorders are more prevalent in countries where food is prevalent and beauty is linked to being thin Immigrants from cultures where eating disorders are rare may develop eating disorders as they assimilate the thin ideal body image Eating disorders are equally common among Hispanic and white women but are less common among African American and Asian women

16. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment: Anorexia Nervosa Setting depends on severity of illness –Medical management; risk of suicide is significant oWeight restoration oNutritional rehabilitation oRehydration oCorrection of electrolyte imbalances oSupervised access to a bathroom to prevent purging

17. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychopharmacology –Amitriptyline (Elavil) and the antihistamine cyproheptadine (Periactin) can promote weight gain –Olanzapine (Zyprexa) because of its effect on body image distortions –Fluoxetine (Prozac) prevents relapse Psychotherapy –Family therapy –Individual therapy Treatment: Anorexia Nervosa (cont’d)

18. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment: Bulimia Nervosa Most clients are treated on outpatient basis: –Cognitive-behavioral therapy –Psychopharmacology oAntidepressants  Desipramine (Norpramin)  Imipramine (Tofranil)  Amitriptyline (Elavil)  Nortriptyline (Pamelor)  Phenelzine (Nardil)  Fluoxetine (Prozac)

19. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Application of the Nursing Process: Eating Disorders Assessment –History: oAnorexia: model child, no trouble, dependable, before onset of anorexia oBulimia: eager to please and conform, avoid conflict, but may have history of impulsive behavior

20. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment (cont’d) –General appearance and motor behavior: oAnorexia: slow, lethargic, even emaciated; slow to respond to questions, difficulty deciding what to say, reluctant to answer questions fully; often wear baggy clothes; limited eye contact; unwilling to discuss problems or enter treatment oBulimia: normal appearance; open and talkative Application of the Nursing Process: Eating Disorders (cont’d)

21. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment (cont’d) –Mood and affect oAnorexia: sad and anxious; seldom smile or laugh oBulimia: initially cheerful but express intense emotions of guilt, shame, and embarrassment when discussing binging and purging behaviors Application of the Nursing Process: Eating Disorders (cont’d)

22. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment (cont’d) –Thought processes and content: spend most of the time thinking about food, dieting, food-related issues; body image disturbance is delusional oAnorexia: paranoid ideas about their family and healthcare professionals being the “enemy” that is trying to make them fat Application of the Nursing Process: Eating Disorders (cont’d)

23. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment (cont’d) –Sensorium and intellectual processes: generally alert, oriented, intact; exception is the severely malnourished client with anorexia, who may have mild confusion, slowed mental processes, and difficulty with concentration and attention Application of the Nursing Process: Eating Disorders (cont’d)

24. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment (cont’d) –Judgment and insight: oAnorexia: very limited insight and poor judgment about health status oBulimia: insight into the pathologic nature of their eating behavior but feel out of control and unable to change that behavior –Self-concept: low self-esteem; see themselves as powerless, helpless, and ineffective Application of the Nursing Process: Eating Disorders (cont’d)

25. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment (cont’d) –Roles and relationships: oAnorexia: may have failing grades in school, in sharp contrast to previous high-level performance; withdraws from peers oBulimia: ashamed of binging and purging, hides it from others; the amount of time spent buying and consuming food can interfere with role performance –Physiologic and self-care considerations: exhaustion, trouble sleeping, sores in the mouth, dental problems Application of the Nursing Process: Eating Disorders (cont’d)

26. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Data analysis –Nursing diagnoses may include: oImbalanced nutrition: less than/more than body requirements oIneffective coping oDisturbed body image Other diagnoses such as deficient fluid volume, constipation, fatigue, and activity intolerance may be indicated Application of the Nursing Process: Eating Disorders (cont’d)

27. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Outcomes –The client will: oEstablish adequate nutritional eating patterns oEliminate use of compensatory behaviors such as laxatives, enemas, diuretics, and excessive exercise oDemonstrate non–food-related coping mechanisms oVerbalize feelings of guilt, anger, anxiety, or excessive need for control oVerbalize acceptance of body image with stable body weight Application of the Nursing Process: Eating Disorders (cont’d)

28. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention –Establishing nutritional eating patterns –Helping client identify emotions and develop coping strategies –Dealing with body image issues –Client and family education Application of the Nursing Process: Eating Disorders (cont’d)

29. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation –Evaluation may involve use of an assessment tool to measure progress –Body weight within 5% to 10% of normal –No medical complications from starvation or purging Application of the Nursing Process: Eating Disorders (cont’d)

30. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Community-Based Care Hospital admission is indicated only for medical necessity: –Dangerously low weight; electrolyte imbalances; renal, cardiac, or hepatic complications; clients who cannot control the binge/purging cycle Community settings include partial hospitalization or day treatment programs, individual or group outpatient therapy, and self-help groups

31. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Mental Health Promotion Educate parents, children, and young people about strategies to prevent eating disorders Early identification and appropriate referral Routine screening of young women for eating disorders

32. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues Feelings of frustration when client rejects help Being seen as “the enemy” if you must ensure the client eats Dealing with own issues about body image and dieting